Refocused vaccination campaigns are possible
Local planning should go hand in hand with equitable plans at national and global levels
Poornima and Ashok, 80, parents of two and grandparents of three, have been crammed into their Bombay apartment for a year. When a COVID-19 vaccine became available in March 2021, they went to the local hospital to get their first dose of Covishield vaccine from the Serum Institute of India – the vaccine that was supposed to save the world. Seeing long lines and not wanting to risk being infected while waiting to be vaccinated, they returned home. It happened again the next day before a very helpful staff member from the World Health Organization (WHO) stepped in to help them, taking them to a health facility early one morning and making sure that they don’t have to stand in line to get vaccinated. It happened again in April 2021 for their second dose. This couple got lucky.
Where the focus should be
As we envision what promises to be a transition from a lack of vaccine supply to greater availability, the plan must be to prioritize people like Mumbai’s two octogenarians – elderly people who do not. are not vaccinated and are at high risk. Be sure to vaccinate them before opening the vaccination to young adults. This would prioritize people based on critical illness risk and need – essential principles if we are planning in the spirit of justice.
Local governments and municipalities should also prioritize vaccines for historically marginalized people by focusing on the prism of equity and justice. What does it mean to focus for equity and justice? This would mean ensuring that the vaccine rollout does not lead to preventable differences in vaccine uptake – and therefore preventable disease and death – between marginalized groups and the rest of the country. This would require prioritizing the poor, religious minorities, socially disadvantaged castes, Adivasi communities, those living in remote areas and women.
The government of Chhattisgarh is an example of an equity-focused immunization plan. The plan prioritized ration card holders, especially because they are poor and often live in larger, multigenerational households, putting them at higher risk of infection. They often do not have access to cell phones and the Internet, which are necessary to register for immunization. Although the High Court has called for the plan to be changed to provide vaccines to the general public alongside ration card holders, we would suggest prioritizing the marginalized when vaccine supply is limited to minimize the risk of serious consequences due to COVID-19. WHO Strategic Advisory Group of Experts on Immunization recommends prioritizing socio-demographic groups with significantly higher risk of serious illness or death (for vaccination) in a context of limited supply. We must ensure that we remove barriers to immunizing the most vulnerable in India to minimize preventable disease and death.
India was and continues to depend on the AstraZeneca vaccine because it was stable in the refrigerator for long periods of time than mRNA vaccines. Presumably, this was so that vaccines could be available where freezers do not exist. But it also makes it possible to transport the vaccine in vaccine carriers and bring it to people where they are. In Indian villages, Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) have extensive experience and expertise in polio pulse vaccination and neonatal vaccination; their expertise must be used to bring vaccines to the villagers.
Slums and urban neighborhoods, where disadvantaged castes and community groups and migrants from Adivasi communities often reside, have limited access and low confidence in the health system. Vaccines should be provided in camps or door-to-door in these areas. Rightly so, local governments are considering providing vaccines to the elderly through door-to-door campaigns. A similar approach – vaccination camps where people live and work – could also dramatically improve vaccination among essential workers and the poor. We need to ensure that those who work for a daily wage can get vaccinated without having to give up work or pay.
Adivasi communities also reside in remote and wooded areas which are also ravaged by waves of deaths, possibly due to COVID-19; vaccine distribution should be a priority in the districts where they live. In India today, perhaps the most marginalized are religious minorities, especially poor Muslim communities. Vaccine distribution should also be a priority in Muslim-dominated Tier 3 cities across the country. An explicit focus on justice would prioritize the engagement of trusted spokespersons to engage in effective risk communication with vulnerable and marginalized communities, and to build confidence in the vaccine.
Vaccination days reserved for women
We need women-only immunization days to ensure women know they are a priority. During the 1918 influenza pandemic, India was one of the few places where mortality was higher in women than in men, and we barely understand the drivers of this observation. In the current pandemic, it is very possible that if women are not explicitly prioritized, economic pressures to protect the breadwinner (often male) and the historically marginalized stature of women in society will eventually lead to gender inequalities. in vaccination. – the first signs of this were recently reported.
Unfortunately, our data during the pandemic does not allow us to examine whether gender, caste, religious, and indigenous identities impacted the risk of SARS-CoV-2 infection or death. Despite global calls for better monitoring, including among vulnerable groups, India does not even regularly report data disaggregated by sex. Despite efforts to collect and make data available, the reporting of geographic and other metadata for tests performed and samples sequenced varies by laboratory and state. Better leadership to standardize and enforce timely metadata collection and reporting is essential to inform data-driven interventions and priority resource mobilization.
Equity and justice
Local planning will need to go hand in hand with a refocus on equity and justice at the national and global levels as well. Nationally, people have recognized that digital apps for recording are a recipe for inequality across age, gender and economic dimensions, and reports have highlighted the plight of those who are. on the wrong side of the digital divide. CoWIN data available to date show that vaccination rates have been inequitable between tribal and non-tribal areas, for example. Going forward, let’s focus on doing no harm first: getting people vaccinated to save the lives most at risk. Nationally, the recent decision to centrally procure vaccines and make COVID-19 vaccines available for free through the public system go a long way in ensuring fairness and justice. WHO has repeatedly called for the urgent need for equity in vaccines globally. In an ideal world, vaccines would be procured and distributed equitably to countries as needed through COVAX installation. But instead, rich countries have again, as in the 2009 H1N1 influenza pandemic, got more doses than needed to vaccinate each member of their population, and even pre-ordered booster doses. This leaves only the poor countries dependent on supply through COVAX, and they end up at the end of the line. This is a wake-up call for the establishment of vaccine distribution systems for the sake of equity for the next pandemic. Currently, unfortunately, poor countries are at the mercy of the European Union and the United States, which must donate vaccines now. They must immunize the world alongside their own communities – they must immunize grandparents everywhere alongside children and adolescents within their borders. Work carried out during the 2009 H1N1 influenza pandemic showed that the willingness of the American public to donate vaccines to the poorest countries was appreciable. Even today, polls show that American public support for the immediate donation of the COVID-19 vaccine exists. Doses should be donated to COVAX now so that they can be distributed to countries as needed. Every life matters in this world and world leaders must follow the example of the WHO and embody global solidarity in this pandemic.
Refocused and rejuvenated local, national and global vaccination campaigns are possible. Let’s make sure we plan now to have those shots when they are available. Let’s get to work in India.
Supriya Kumar is a public health researcher focusing on health equity in South Asia. NS Prashanth is a faculty member at the Bengaluru Institute of Public Health